Thursday, July 30, 2015

My buddy Jeff Thompson is stepping down as CEO of Gundersen Health System in a few months. I have commented several times here on Jeff's leadership abilities, which are again demonstrated in a note he sent to his staff this week. In simple, direct terms he reinforces the narrative that is at the heart of his hospital's purpose. It could be the same purpose of any hospital in the world, but it is not often set forth so well. An element of leadership is that the narrative is expressed in so eloquent and elegant a fashion--one that permits all recipients to feel ownership of the privilege and obligation they have been given.

Dear Colleagues,

We are experiencing many changes as an organization. Some are very
exciting like Dr. Rathgaber taking over as CEO in September. Others are
more of a struggle. There is always going to be change, especially in
our business.

But it is not the changes that are the most important. It is how we respond. How we respond to change as individuals, teamsand as an organization is what defines us. It will determine our futures and move us from good to great.

Sounds good, but change can be very scary.

Here’s what won't change: Our mission to improve care, lower costand improve the health of the community. This rises beyond growth
targets, financial goals and facilities plans. It really is an
individual and organizational moral obligation.

To take on big responsibility and big changes, it is best to start
with a great platform as a base. The solid platform we have should give
us great confidence going forward. In the face
of higher quality standards, economic
down turns, tons of regulation and increasing competition, you as teams
and we as an organization have steadily improved on all of our key
strategies.

Going forward it boils down to just a couple of really big things:
Take care of our patients and take care of each other. The "patient"
part has expanded to "patients, families and communities" and each other
needs to include those well beyond our immediate
work groups to colleagues and partners.

Although changes will always cause some struggles, we have no reason
to fear them. We need to trust our strong platform, our clear path and a
great team to not just survive but truly excel through the change.

Wednesday, July 29, 2015

Here's a quiz. Can you guess who posted the following messages on Twitter?

Any idea how many hospital execs' bonuses are tied to their institution's U.S. News rankings?

When execs confide this arrangement, they expect me to be impressed or flattered. Are you kidding? I'm deeply disturbed. In my view it's a symptom the board has abdicated its responsibility to measure, monitor & incentivize quality improvement.

You might be surprised to learn that it was Ben Harder, @benharder, chief of health analysis at US News and World Report, the magazine that publishes "data, rankings & tools to help consumers choose hospitals, doctors, health plans & more."

Probably more than anyone in the country, Ben understands the inherent limitations in any such rankings. More important, he understands that the rankings are designed to advise patients with complex medical conditions. They are not an indication about the general level of quality of care or safety in an institution.

He certainly knows that hospitals use the rankings in their marketing materials, but he understands that what makes marketing effective is different from what makes it possible for a hospital to deliver the highest level of care and to engage in ongoing clinical process improvement.

Bravo to Ben for putting this out there so clearly. I'm hoping board members take note.

Tuesday, July 28, 2015

Here are some excerpts from just a few blog posts written by medical and nursing students after the first day the Napa version of the Telluride Patient Safety Camp (seen here having lunch!) I encourage you to read others:

--

They would act as though nothing is wrong.

I wrote this quote down on my pad during the Lewis Blackman video
that was shown today because I’ve been guilty of this during rotations
myself. Hellen Haskell, Lewis’ mother, was talking about the nurse
taking care of her son and the fact that nursing notes ultimately
revealed that she was indeed deeply concerned about the patient and his
deteriorating clinical condition.

The truth is I don’t quite know how to act (maybe act is the wrong
word) or rather what emotions to show around families. No one ever tells
you to show a impassive face, to act as if everything is proceeding
according to plan even when your team is struggling to figure out what
is wrong, yet this is exactly what one learns observing the behavior of
residents and attendings.

I suppose I always assumed that it was more comforting for families
to feel like the providers had a handle on the situation. However,
having heard from the patient and patient family perspective, I
recognize how isolating and invalidated it can be to feel as if you are
the only one concerned about your loved one’s care. While there is a
time, a place, and an extent to which to share one’s emotions with
patients and their families, honest communication throughout a patient’s
stay can create a foundation of trust that can be critical in the
terrible event an adverse outcome occurs. (Neelaysh Vukkadala)

--

We started the day with the Lewis Blackman story. It was a very
sobering, raw look at what healthcare should not be. Everything that
could go wrong did in this case. No one could see the forest for the
trees. I felt sad as a provider, devastated as a parent and could not
imagine the strength that Helen has to go on and share this with others.

The whole story reminded me of my mother in law (who had cancer). She
had epigastric pain & went to the ER. She was told she was
constipated from her pain meds-and they missed her massive MI.
Mom walked into the ER but never walked out. She lived the rest of her
days (2 months) in a nursing home since she could no longer care for
herself due to the injury from the missed MI. She ultimately died from
heart failure shortly after her MI-not the cancer she had been battling.
We thought she would be with us for about another year-but we got that
time stolen from us. In our case, my husband and I talked and decided
not to pursue legal action since we knew she likely did not have much
time left. He approached someone who he was friends with in hospital
administration and let him know about the missed MI. He told him that he
didn’t plan to pursue any legal action but did want to talk about how
this could be avoided in the future. The guy he thought was his friend
suddenly did not take his calls anymore. How sad. There are far too many
stories like this. (Tanya Celia)

--

Throughout the day, I couldn’t help but keep thinking about the
importance of communication between the healthcare team and the patients
that they serve. If there is no transparency, patients and their loved
ones (even those well-versed with the medical system) feel like they are
left in the dark — during the most stressful time of their lives, they
have the added burden of trying to figure out what it is their doctors,
nurses, and auxiliary team are actually doing. Lewis Blackman’s story is
powerful in that it illustrates the importance of honesty. Watching the
video left me with so many ‘if; statements. If the resident or intern
working with the nurses had taken pause to discuss Lewis’s worsening
condition, could this all have been avoided? What if the doctors and
nurses had been more upfront about their lack of understanding of
Lewis’s situation? What if Helen had been able to directly contact the
attending, would he/she have listened to her pleas and ordered tests to
reveal the ulcer? What if there had been a system implemented in the EMR
to alert attendings when vital signs were out of whack? As an engineer
by training, I believe we should create a framework so that even when
humans make mistakes, the system in which we operate is able to provide a
safety net to catch that one mistake that could mean life or death. (Sunny Kung)

---

As students of medicine, we are constantly learning:
from understanding how to create a robust differential diagnosis, to
figuring out ways to chart a patient’s progress through an electronic
health record. We drink thousands of new words from a firehose every
day, hoping to eventually master the mesmerizing and powerful medical
language. With this constant influx of new information, it is easy to
forget perhaps the most important facet of our patients’ care: a
meaningful relationship founded upon trust. Regardless of the hours
spent memorizing biochemistry textbooks, if we as health care
professionals cannot find a way to communicate with our patients, we
will fail to provide our patients with high quality care. (Serena Dasani)--The general feeling I left the end of Monday with was discomfort. The
idea that I will be taking the reins on patient care in three short
years is a terrifying thought. I hope that I can draw on lessons from
Telluride to remember to stay goal oriented, patient centered, and most
of all scared in order to provide safe, quality care. (Alexandra Butz)

--

The corridor faded as her trust weakened
Ending a life, hopes, and dreams
Learning to cope with how we failed her
Leaving her impressions fluid in the rigid system
Unavailable.
Rising and challenging us to remember the center
Instill our pledge in our actions
Demanding change to our discussions
Establishing humanity in our calling (Natalie Elder)

The Risk Management Foundation of CRICO recently supported a research program to test the effectiveness of 360 degree reviews in influencing surgeons' communication and behavioral skills. The results were just published in the Journal of the American College of Surgeons.

The context was important:

The program was deployed as part of a long-standing, surgical chief-led
patient safety and quality collaborative. The collaborative had
previously constructed a Code of Excellence (COE), an explicit
description of behaviors expected of all surgeons within their
departments. The 360 degree evaluation process was designed to assess
progress towards these standards.

Here's how the study was designed:

Three hundred and eighty five surgeons in a variety of specialties [in the Harvard hospitals] underwent 360-degree evaluations with a median of 29 reviewers each. Beginning six months after evaluation, surgeons, department
heads, and reviewers completed follow-up surveys evaluating accuracy of
feedback, willingness to participate in repeat evaluations, and behavior
change.

Here are the results:

Survey response rate was 31% for surgeons, 59% for
department heads and 36% for reviewers. Eighty
seven percent of surgeons agreed that reviewers provided
accurate feedback. Similarly, 80% of department heads felt the feedback
accurately reflected performance of surgeons within their department.
Sixty percent of surgeon respondents reported making
changes to their practice based on feedback received. Seventy percent of
reviewers elt the evaluation process was valuable with
82% willing to participate in future 360 degree reviews.
Thirty two percfent of reviewers reported perceiving
behavior change in surgeons.

And the conclusions:

360-degree evaluations can provide a practical, systematic, and
subjectively-accurate assessment of surgeon performance without undue
reviewer burden. The process was found to result in beneficial behavior
change according to surgeons and their co-workers.

Monday, July 27, 2015

When the history of the patient safety movement is told, it will be appropriate that the Association of American Medical Colleges* will be left out. The recalcitrance of this organization in acknowledging patient safety problems was legendary for the first decade of this century. The AAMC's leadership not only refused to acknowledge the depth of patient harm but also precluded use of the organization's arms in working on the issue.

For example, when an AAMC committee was to be established in the mid-2000's on patient quality and safety issues, the leadership insisted that the word "safety" be omitted from the committee's name and charter.

For example, when people would submit articles on patient safety to the AAMC's main journal, Academic Medicine, they would be summarily refused, refused even the courtesy of peer review. The authors were told that patient safety was not an issue of public concern and therefore did not warrant space in the journal.

For example, at sessions with the world's experts on patient safety and doctor education (like Don Berwick and Lucian Leape), high officials from AAMC would reiterate their belief that hospitals did not have a patient safety problem.

Things finally changed in 2010, when a new CEO arrived. In an article, he and the organization's president addressed the issue:In order to develop a health care culture of safety that leads to
clinical improvements, an unprecedented collaboration between medical
schools and their partnering health systems is required, according to
Drs. Kirch and Boysen. They identify five factors critical to the
success of a culture shift: leadership from the top, student
involvement, a focus on safety during residency training, health
information technology, and teamwork among health professionals. “When
combined with a growing investment in comparative effectiveness
research, these factors will help physicians improve care at the
bedside,” the authors write.

I suppose better late than never, but think about the societal loss caused by the absence of the major academic medical organization from this issue for so long--notwithstanding important findings by the Institutes of Medicine on the topic.

Perhaps the AAMC leadership reflected the views of its membership. I recall, when I was emphasizing patient harm on this blog and posting clinical outcome data, the Chair of the Partners Healthcare System called the Chair of our system and said, "Can you get Paul to stop publishing those numbers. This is bad for academic medicine."

Or perhaps the membership took direction from the AAMC leadership, who, after all, were highly regarded in the profession. Either way, the lack of action on and attention to patient safety was a significant failure and led to the slow inclusion of patient safety curricula in America's medical schools. Let's consider, therefore, that the AAMC contributed for years to the delay in addressing the large number of preventable deaths and harm in America's hospitals.

--

* As noted in its materials: The Association of American Medical Colleges is a not-for-profit
association representing all 144 accredited U.S. and 17 accredited
Canadian medical schools; nearly 400 major teaching hospitals and health
systems, including 51 Department of Veterans Affairs medical centers;
and nearly 90 academic and scientific societies. Through these
institutions and organizations, the AAMC represents 148,000 faculty
members, 83,000 medical students, and 115,000 resident physicians.

A hearty welcome to the newest participants in the Telluride Patient Safety Summer Camps, taking place this week in Napa, CA. Here's a sample of the medical students and nursing students who are attending:

Sunday, July 26, 2015

Back in 1962, John Steinbeck published Travels with Charley, a series of stories and observations from interactions with people across America. I happened to pick it up yesterday to re-read it, about 50 years after the first time it was assigned to me in junior high school. Early in the book Steinbeck relates a discussion he has with a New Hampshire farmer about what was still a major post-World War II concern, the recent development and spread of nuclear power and weapons.

The farmer says,

"Take my grandfather and his father. They knew some things they were sure about. They were pretty sure give a little line and then what might happen. But now--what might happen?"

"I don't know," responds the author.

"Nobody knows. What good's an opinion if you don't know. My grandfather knew the number of whiskers in the Almighty's beard. I don't even know what happened yesterday, let alone tomorrow. He knew what it was that makes a rock or a table. I don't even understand the formula that says nobody knows. We've got nothing to go on--got no way to think about things."

The farmer leaves and Steinbeck reports (my emphasis):

"I found I couldn't read, and when the light was off I couldn't sleep. The clattering stream on the rocks was a good reposeful sound, but the conversation of the farmer stayed with me--a thoughtful articulate man he was. I couldn't hope to find many like him. And maybe he had put his finger on it. Humans had perhaps a million years to get used to fire as a thing and as an idea. Between the time a man got his fingers burned on a lightning-struck tree until another man carried some inside a cave and found it kept him warm, maybe a hundred thousand years, and from there to the blast furnaces of Detroit--how long?

"And now a force was in hand how much more strong, and we hadn't had time to develop the means to think, but man has to have feelings and then words before he can come close to thought and, in the past at least, that has taken a long time."

140 scientists gathered here in 1975 for an unprecedented conference. They were worried about what people called “recombinant DNA,” the
manipulation of the source code of life. It had been just 22 years since
James Watson, Francis Crick, and Rosalind Franklin described what DNA
was.

Preeminent genetic researchers like David Baltimore, then at MIT,
went to Asilomar to grapple with the implications of being able to
decrypt and reorder genes. It was a God-like power—to plug genes from
one living thing into another. Used wisely, it had the potential to save
millions of lives. But the scientists also knew their creations might
slip out of their control. They wanted to consider what ought to be
off-limits.

At the end of the meeting, Baltimore and four other molecular biologists
stayed up all night writing a consensus statement. They laid out ways
to isolate potentially dangerous experiments and determined that cloning
or otherwise messing with dangerous pathogens should be off-limits. A
few attendees fretted about the idea of modifications of the human “germ
line”—changes that would be passed on from one generation to the
next—but most thought that was so far off as to be unrealistic.
Engineering microbes was hard enough. The rules the Asilomar scientists
hoped biology would follow didn't look much further ahead than ideas and
proposals already on their desks.

But then:

Earlier this year, Baltimore joined 17 other researchers for another
California conference. The stakes, however, have changed. Everyone at the Napa meeting had
access to a gene-editing technique called Crispr-Cas9, [which] makes it easy, cheap, and fast to move genes around—any
genes, in any living thing, from bacteria to people. “These are monumental moments in the history of biomedical research,” Baltimore says. “They don't happen every day.”

Using the three-year-old technique, researchers have already reversed
mutations that cause blindness, stopped cancer cells from multiplying,
and made cells impervious to the virus that causes AIDS. Agronomists
have rendered wheat invulnerable to killer fungi like powdery mildew,
hinting at engineered staple crops that can feed a population of 9
billion on an ever-warmer planet.

Bioengineers have used Crispr to alter
the DNA of yeast so that it consumes plant matter and excretes ethanol,
promising an end to reliance on petrochemicals. Startups devoted to Crispr have launched. International pharmaceutical and
agricultural companies have spun up Crispr R&D. Two of the most
powerful universities in the US are engaged in a vicious war over the
basic patent. Depending on what kind of person you are, Crispr makes you
see a gleaming world of the future, a Nobel medallion, or dollar signs.

The technique is revolutionary, and like all revolutions, it's
perilous. Crispr goes well beyond anything the Asilomar conference
discussed. It brings with it all-new rules for the practice of
research in the life sciences. But no one knows what the rules are—or
who will be the first to break them.

Now, think back to Steinbeck:

"And now a force was in hand how much more strong,
and we hadn't had time to develop the means to think, but man has to
have feelings and then words before he can come close to thought and, in
the past at least, that has taken a long time."

In the past, it was the military-industrial complex, now it's the medical-industrial complex. Driven by ego of people who are too sure of themselves and the greed of those seeking to park their cash, the likelihood of effective and thoughtful controls is likely to proceed at too slow a rate to protect us from ourselves. Now here's an issue worthy of attention by the multitude of presidential candidates: Will any step up to address it?

Saturday, July 25, 2015

I recall a wonderful story from Amitai Ziv, the
director of MSR, the Israel Center for Medical Simulation at Sheba Medical Center on the outskirts of Tel Aviv. He relates how Israeli fighter pilots would return from their missions and debrief how things went. The self-reported reviews of performance were very good. Then, the air force installed recording devices on the planes, and it turns out that the actual performance was not nearly as good as had previously been reported. The conclusion: It's not that people are poorly intentioned or attempt to mislead about their performance. It's just that we tend to think we are doing better than we actually are.

Let's turn to health care. Here's a recent story by Lisa Rapaport at Reuters that portrays a problem and--as in the Israeli example above--demonstrates the importance of transparency--providing staff in a hospital with actual data about their clinical performance. The lede:

Many hospitals overestimate how quickly they give stroke patients a
clot-busting treatment designed to help minimize damage, a U.S. study
suggests.

Researchers asked hospital staff how fast they administered an
intravenous (IV) therapy known as thrombolysis to dissolve clots and
compared the answers to stroke registry data with the actual times.

Only 29 percent of hospitals had an accurate sense of their own
speed.

“Everyone likes to think that they are doing better,” senior study
author Dr. Bimal Shah, a researcher at Duke University School of
Medicine.

The slowest hospitals were also the ones most likely to be inaccurate about their results.

The gap between perception and reality was far bigger for hospitals that were generally slower.

Among the lowest-performing hospitals, staff surveyed generally
thought that at least 20 percent of treated patients got the therapy
within an hour. In reality, none did.

Despite their lack of speed, 85 percent of the low-performing
hospitals reported their performance as average or above, with almost 5
percent of them ranking themselves as superior in comparison with other
hospitals nationwide.

Those of us who are Lean adherents believe in the idea of visual cues, providing data about an organization's performance in real time to those working in an area. That information helps a place monitor its performance and look for ways to improve and sustain improvement.

It looks like stroke centers and their patients could benefit from such real-time reporting. As Dr. Shah notes, “Not acting quickly makes the prognosis for stroke patients worse.”

Friday, July 24, 2015

I've been enjoying an exchange over at Twitter with Ben Harder, @benharder, chief of health analysis at US News and World Report. As he notes, "We publish data, rankings & tools to help consumers choose hospitals, doctors, health plans & more."

In previous posts, I've expressed major reservations about the methodology used by the magazine. Regular readers might recall my 2011 column where I said:US News needs to stop relying on unsupported and unsupportable
reputation, often influenced by anecdote, personal relationships and
self-serving public appearances.

To his credit, Ben has been working on creating a more objective basis for his magazine's rankings, but there is a still a major component that relies on doctors' opinions. I wish him well in continuing to make this whole exercise more scientific. (By the way, as the magazine notes, their ranking is not for patients with "normal" levels of acuity, but rather is designed to focus on which hospitals best handle the more complex cases. You'd never know that based on how hospitals use the rankings in their advertisements.)

Meanwhile, it has been revealing to focus on other comments in the Twitterverse and blogosphere that have attacked as unconscionable recent stories from ProPublica in which Medicare data on readmissions were used to describe complications rates for America's surgeons. Oddly, I cannot recall any of the authors of those diatribes taking on any methodological aspects of the US News rankings.

My guess is that the US News rankings have become such an important part of the marketing campaigns of America's hospitals and doctors that any such problems fall away in the eyes of the profession.

Surgeons' work on "assessing and improving surgical outcomes...will take some time. It’s complex."

I responded:

NSQIP has existed for years. No indication that it will be used for public reporting. Ever. [Note: More on that here.]

I also noted:

Also c new AUA data effort: "By urologists. For urologists." Public
disclosure not contemplated. U c progress. I c recalcitrance. [Note: Check here for a description of the American Urological Association Quality Registry inititaive.]

His reply:

You may be right. But the winds of change are blowing. Growing # of surgeons want #NSQIP to open up.

I offered:

Winds of change? More like gentle whispers. As we say in politics, count the votes. Inertia's winning.

He answered:

You see cup empty. I see rain clouds.

I added:In short, the medical priesthood prevails: "You are not worthy to judge us."

He answered:

Priests will be priests. The congregation is losing its religion.

To which all I can now do is respond by saying, "We shall see." I see nothing on the horizon that suggests that the public's need to know is as yet offsetting the profession's desire to hold things close to the vest. When the numbers suit them, the profession extolls the results. When the numbers don't suit them, it's back to: "The data are wrong. My patients are sicker."

Perhaps you don't want discouraging news about electronic health records. If that's the case, browse on to another site. However, the authors of this new paper have some important things to say. And they have the expertise to be credible, being part of the National Center for Human Factors in Healthcare.

The short version is that EHRs have not been designed with sufficient attention to human factors and therefore are likely to be not as usable as they should be and--I extrapolate--have the potential to cause harm.

First, some background on the topic:

The
usability of any device or system can be broken down into two major
categories: basic interface design (human factors [HF] 1.0) and
cognitive support of the user (HF 2.0). The basic interface design
should follow well-established principles that ensure information is
clear and readable, such as font size and color, while also providing
adequate contrast between text and the background. Focused on the
cognitive support of the user, HF 2.0 entails much greater detail and a
deep understanding of the workflow and cognitive needs of the user.
Designers focusing on HF 2.0 principles seek to understand how users
accomplish their work in the context of their actual work environment
(e.g., observations, task analysis, and other ethnographic techniques)
and engage in iterative user testing of the interface throughout the
development process.

Next, an assessment of the "state of the art:"

We
are . . . concerned about the lack of progress in addressing HF 2.0
challenges. Nearly all EHR vendors, both large and small, struggle with
the challenge of designing for numerous permutations of workflows,
clinical specialties, and physical environments in which their EHRs are
deployed.(
Yet these systems must be designed with the cognitive needs of the
frontline users in mind for each specialty and each user role
(physician, nurse, tech, clerk, etc.). For example, an HF 1.0 patient
discharge tool may have the necessary textbox fields that allow the
provider to enter all of the important discharge instructions. But an
interface incorporating HF 2.0 design principles would ensure easy
access and display of relevant nursing notes, changes in patient status
and vital signs, automatically highlight abnormal test results, and
suggest follow-up information based on those results. In current
systems, abnormal findings and change in a patient's status are easily
missed during the discharge process, despite the fact that the
information is contained somewhere in the EHR, just not presented in a
meaningful way to the user.

Recommendatons:

To
do this well, EHR vendors, health care systems, and frontline health
care workers need to partner so that all can deeply appreciate the
intersection between the technology and the users and design the system
accordingly. These efforts must leave adequate time for testing the
systems during the development process, and should not be rushed after
the system is built and ready to be implemented.

From
our experience in studying EHRs and their implementations, we believe
that health care systems and vendors would be well served by a library
of lessons learned and use cases that they can draw upon to design and
install their systems. Too often, health care systems undertaking a new
EHR installation find themselves reinventing the wheel and repeating the
same mistakes and missteps that another institution made previously.
This is neither sustainable, nor desirable when it comes to implementing
safe and efficient health IT systems.

Wednesday, July 22, 2015

Highmark Health has started a new program to introduce innovative products to doctors and patients. Here's the summary:

"Technologies that have received regulatory approval from the FDA
often lack sufficient scientific data to convince commercial insurers to
pay for them. Without support from commercial payers, it is difficult
for new innovations to influence the practice of medicine.

"VITAL’s mission is to leverage Highmark Health's position as one
of the largest integrated health care delivery and financing systems in
the nation to accelerate the pace with which novel technologies and
services are made available to our customers. In doing so:
• Members and patients will be afforded access to safe new technologies without undue financial burden.
• Payers will be able to understand the full impact of new technologies
on their members without changing insurance medical policy prematurely.
• Providers will gain early access to novel technologies and a first-hand understanding of their impact on patients.
• Technology vendors will have the opportunity to prove the benefits of
their new innovations to patients, providers and payers.

"The VITAL innovation program is essentially a test bed designed to
facilitate early use of technologies that have received regulatory
approval and are being used for their intended purpose within the
approved patient population but are not yet covered by most commercial
insurers. VITAL is designed to provide the missing link between FDA
approval of an innovative technology and its full reimbursement."

This is interesting. I view this program as a mechanism to moderate the tension between a desire to get new technologies out quickly and analyzing the clinical efficacy and cost effectiveness of those same technologies. This will be a good one to watch over the coming months and years.

Tuesday, July 21, 2015

If you were going to invest $300 million in the health care of New York City residents, how would you spend it? In an era of "population health," would you spend it on a single 115,000-square-foot project to provide proton beam therapy?

Construction of the VOA Associates-designed complex will begin this summer with the first patient expected to receive treatment in the spring of 2018. Goldman Sachs and JPMorgan Chase & Co. provided financing.

I met David Meerman Scott many years ago and was impressed with his perspicacity regarding social media. He was a man ahead of his time in understanding the potential for these new platforms to reach out inform, and entertain--as well as to waste your time!

Even now, he regularly produces gems of insight. Here's one from just a few days ago. A teaser:Social
networks are a great place to share content, to interact with others,
to listen in on what’s happening, and yes, if approached carefully,
social networks can be a way to get the word out about you and your
business. However as I review people’s business-related social streams I
find way too much selling going on.

As
a way to think about your social activities, I’d suggest you should be
doing 85 percent sharing and engaging, 10 percent publishing original
content, and only five percent or less about what you are trying to
promote.

If you are trying to sell, it's well worth your while to read the rest.

Monday, July 20, 2015

Please click over to this new article I have published on the athenahealth Leadership Forum. I'm hoping you will post comments. Thanks.

An excerpt:

It’s
often said that we learn from our mistakes. Indeed, many a business
course in leadership offers that premise as a given. I’ve glibly
repeated this often in my classes, speeches, and advisory work.“You don’t learn from your successes,” I point out, “but rather from your errors.”But do we really learn from our mistakes as a matter of course?My friend and colleague Michael Wheeler, in his wonderful book The Art of Negotiation, warns us that it is "all to easy to be overconfident about our ability to observe and learn."

From restaurant kitchens, to flight operations on aircraft carriers, to sports, we have come to understand the value of taking a few seconds as a team to review the current situation, agree on a plan of action, and identify possible contingencies.

In addition, this moment of face-to-face intimacy reestablishes the human connections among the team members.

Paradoxically, it both reinforces the chain of command and re-empowers all of the team members to call out concerns.

Health care, though, has been late to this technique. How pleasing then to read of yet another hospital setting in which it has become part of the standard work.

This report from the Saskatoon Health Region relates the story of "bullet rounds," their form of huddle. Excerpts:

It’s 11 am. In Clinical Teaching Unit (CTU) 6200, a medicine unit at
Royal University Hospital, a group begins to gather near the whiteboard.
Listening to the conversation, you quickly realize they are a diverse
group with doctors, nurses, a speech pathologist, a physiotherapist, a
pharmacist, an occupational therapist, a social worker, and a
representative from client-patient access service (CPAS), to name a few.

Each are handed a list. “Good morning everyone,” says one individual. “We have 20 minutes. Let’s get started.”

For the next 20 minutes, CTU Team ‘Blue’ moves through the unit and
reviews care plans for the day for patients as a team. It’s a process
you will see repeated later in the hour by CTU Team Red and CTU Team
Silver.

How's it working?

“The evidence (behind bullet rounds) is strong. (Daily interprofessional
collaboration) decreases the patient’s length of stay, decreases
hospital errors and decreases hospital admission costs,” Prystajecky
says. “We also know there are other positive outcomes of collaboration
including enhancing team communication and team building.”

And here's a follow-up story, summarizing with the all important continuous improvement goal:

“I am excited to see where this goes,” [Christina Sparrow, CTU nurse coordinator] says. “It’s a great process,
and . . . I am excited to see how we will continue to
change and improve to get better.”

Sunday, July 19, 2015

In 1945, Leah and Sam Sleeper, educators from Worcester, MA, started an overnight camp for boys on a piece of land they owned in Charlton. On the 15th anniversary in 1960, they noted:

[Camp] Wamsutta has always operated on the principle that busy boys are happy boys, and if the "busyness" is channeled into healthy and wholesome areas of activity, busy boys are learning, developing and growing into happy and well-adjusted manhood.

The next year, they noted:

The aim of a well-directed camp program is to achieve order without regimentation; organization without restriction; and excitement and enthusiasm without the pressures of competition. The ideal is silent and inconspicuous supervision in an atmosphere of relaxation.

And in 1962:

Counsellors have competed with each other in developing interesting projects to motivate the campers. The campers in turn have settled down to a well-regulated and healthy pattern of living. Their experiences have been many and rich. They have grown in physical, mental, and moral stature.

It was only upon "preparing" for our camp reunion this past weekend that I pulled out these quotes from camp yearbooks that had lain in an old trunk in my attic for several decades. Several dozen of us met on the shore of Buffumville Lake and reminisced with Marty Sleeper, one of the three sons of the camp founders, who had been intimately involved in camp planning and activities.

Marty himself went on to a career in education, becoming the beloved principal of a school in Brookline and later joining Facing History and Ourselves, where he remains as Special Advisor.

It never occurred to me that the Sleeper's had an educational philosophy for their camp. I just went to camp and played ball and other activities and had a great time for eight weeks each summer from 1959 to 1964. I certainly never considered the impact of the Sleepers' educational philosophy on my own development or my own approach to teaching and coaching.

But, then as I read through the yearbooks, I realized that I had internalized many of their lessons and adopted the principles in my own leadership roles--whether running an academic medical center or coaching girls soccer. "Lead as though you have no authority" is one of my mantras. Trust the people with whom you work, and understand that a key component of your job is to help enable their personal and professional development. Your job is to develop new leaders, not persistent dependence on your supervision.

So, with a belated thank-you to Leah, Sam, and Marty, I engage in a midsummer reflection that we never know when mentors' lessons will take hold or where inspiration will arise.

Wednesday, July 15, 2015

The knives, er scalpels, are out in force, attacking the methodology used by ProPublica in setting forth conclusions about America's surgeons. Here's a piece from Justin McLachlan, essentially accusing ProPublica of journalistic malpractice. Here's another one by Benjamin Davies, calling the work "clickbait."

Let's see, absent access to the secret NSQIP data, which admittedly does not exist for of all surgeons, what are we left with?

What are we left with if I am a referring doctor who wants to send a patient to the best possible surgeon?

What are we left with if I as a patient want to check out the performance record of several surgeons?

What statistically valid methodology is available to me?

I'll tell you what methods are currently in use:

Anecdote. Bias. Personal friendships between doctors. An unsupported feeling that "Dr. Smith does a really good job."

Justin and Benjamin and others, what exactly are you proposing should supplant the entirely subjective and unreliable sources of information currently available? How soon will your idea (if you have one) become feasible and be put into the public domain? Or do you simply propose that we should have less information about picking a surgeon than we do about virtually any other consumer choice we make?

Well, maybe it doesn't matter. Maybe all surgeons are equally competent and have similar records of success. Maybe the personal stakes to me as a patient are too insignificant to matter.

Are falls preventable? Here's a case of inappropriate care by the medical community that caused them. Note my friend--even as a doctor--was unable to get the proper care for her mother:

I
have to tell you about my 93 year old mom:

For years at the nursing home they kept adding blood pressure medicines to treat her recalcitrant
blood pressure. She was falling more than
once a day, disoriented and largely wheelchair bound since the staff
found using the chair prevented falls. (They would wheel her to meals,
etc.) She spent most of her days in bed.

Shortly
before she moved to the dementia unit the doctor came to see her and said
she was on too much blood pressure medication. He noted that old people needed higher pressures,
something I had been trying to tell her previous doctors for a couple
of years.

Bottom
line--he stops all but one blood pressure medication. I ask them to put her on an
antidepressant, and she is now walking around without even a walker. We even took her to IHOP and the grocery store and she had
more stamina than ever before. She is happy.

The entire thing was iatrogenic! --
*Definition: Induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.

Tuesday, July 14, 2015

Here's the issue in a nutshell, as I see it. There is a rigorous methodology available for evaluating surgical outcomes. It is from the American College of Surgeons, and it is called NSQIP. It is indeed the "leading nationally validated, risk-adjusted, outcomes-based program to
measure and improve the quality of surgical care in the private sector."

Takes into account patient risk factors like age and BMI for a growing number of common surgical procedures.

Better predictive ability than most other models.

Ideally, ProPublica or others could publish the NSQIP results, except for one thing. Under the ACS rules, the evaluations must be held confidential.

So there we have it. We could all have a rigorously derived comparison tool, but since the profession chooses not to make it available, we must have a surrogate of the sort that ProPublica used in its article. Or nothing at all. What would be your choice?

Monday, July 13, 2015

ProPublica analyzed 2.3 million Medicare operations and identified
67,000 patients who suffered serious complications as a result:
infections, uncontrollable bleeding, even death. We report
the complication rates of 17,000 surgeons – so patients can make an
informed choice.

No doubt the doctors with poorer statistics will say the usual: (1) "The data are wrong" and (2) "My patients are sicker." Some experts offer their own opinions.

Will the information really help patients make an informed choice? The jury's out on that. It depends on whether primary care doctors use the data to guide their referrals or whether they will continue to rely on friendships and anecdotes--all reinforced by the financial pressures of being in the same ACO as those surgeons.

Brad Flansbaum (again) offers a thoughtful exposition on an important topic, this time frequent flyers (aka super-utilizers) in the emergency room. He notes:

Those individuals present week after week with innumerable complaints,
sometimes pedestrian, sometimes critical–always finding themselves back
on the ward for weeks at a time. As expected, they have weak community
support and comorbidities in need of TLC, often requiring services not
available in their neighborhoods (mental health and substance abuse
counseling come to mind). The local house of worship, community center,
or corner bar have limits, and they only offer so much spiritual renewal
or sustenance. We all struggle to find a balance for these folks. We
see them a lot. And thus, the ER becomes their second home.

After presenting some important data (above), he concludes:

Super-utilizers require a more individualized, unique approach. We need to consider
the needs of these patients separately.

Sunday, July 12, 2015

I’m not a health care person by training. Much of my background is in the public policy
arena—starting first in energy and then branching out to telecommunications,
and thence to water and wastewater. In
parallel, I’ve also run large organizations and managed thousands of people and
billions of dollars in capital and operating budgets. I’ve been a regulator and I’ve been
regulated. When I offer opinions and
illustrative stories on this blog, I am mainly driven by what I see as failures,
and I try to offer approaches that might work to improve things.

In that sense, for almost nine years, the blog has presented a series of
advocacy documents. Regular readers know
that I have seldom pulled my punches: There are enough people who try to be
diplomatic in what they say and how they say it. When it comes to saving lives
from preventable harm, I am too impatient to be overly considerate about
people’s sensibilities.

In all this, I’ve had to decide my own role, beyond what I
do to make a living (providing negotiation training and advice to companies in
many sectors around the world.) I’m
honored to be invited by hospitals and others to provide stories, training, and
maybe even some inspiration as they pursue their journeys towards
patient-driven care. Those journeys rely
on creating learning organizations, characterized by respectful treatment of the staff and
transparency to achieve process improvement to deliver high quality and safe
care.
I’ve chosen to interact mainly with those hospitals that we
have come to view as “islands of excellence in a sea of mediocrity.” I don’t
spend time in places that are not committed to the quality and safety journey
because I only have so much time available and because I don’t find much merit
in hitting my head against a wall.

Admittedly, that’s a luxury on my part, hanging
out with the 5% or 10% of institutions that “get it.”
But what becomes of the rest, the vast majority of hospitals
that don’t get it? My buddy Dave Mayer likes to say that the answer to achieving greater quality and safety and transparency is to “educate the young
and (when necessary) regulate the old.” Beyond the humor, there is an element
of wisdom in Dave’s construction of the argument.

I’ve spent a lot of time on this blog carping about the lack
of rigor that has gone into the design of health care regulation, so I don’t
want to spend time on that today. Suffice it to say that the hand of government is often roughly applied,
and we can only hope that officials get better at designing and implementing policies.

But recent remarks by Bob Galbraith at our student and resident training program (Telluride East) reminded me
that the heart of professional activities must be self-regulation. He posited that the medical
profession has failed in this regard—avoiding discipline of their members who are clearly
impaired, incompetent, and negligent. So, he suggests, fix this they must, or some one will
step in and do it for them.

Bob’s right on his particular point, but we know that most medical harm does not
derive from the individual actions of doctors. It derives from the work patterns and systems that are in place in
hospitals. These are not organizational
aspects in which most doctors and nurses have been trained. They are trainable with some time, effort,
and resources—but those in a position of authority must encourage and demand that it happen. The “those” in this case must be the boards
of trustees, the governing bodies of the hospitals.

But it is in this arena that we have a public policy
lacuna. While trustees often have a
statutory responsibility for the quality of care given in their hospitals, they
are never held accountable for that care. The history of involvement by lay governing bodies is heavily centered
on the social and community aspects of governance, including fund-raising. Clinical decisions are left to the clinical
staff, as they should be, but oversight of clinical activities by the governing body is often rudimentary at best.

It’s time to change this pattern and, where necessary, force
greater engagement by trustees in quality and safety issues. Given the stature
of trustees in the community and their political influence, I don’t expect
legislators to do much on this front. But there is a group that could take advantage of the current situation
and give those trustees a real incentive to learn how to effectively govern
safety and quality.

That group is the medical malpractice plaintiff bar.

Currently, plaintiffs’ attorneys sue the doctors or nurses
or the hospital when someone is harmed and negligence is alleged. The main argument is that the standard of
care was not met, and the focus is usually on the specific actions or non-actions
by the clinical staff.

But it’s time for
a broader definition of negligence: Negligence today is found in a hospital
that has not used the wealth of data and experience garnered around the world
by the “islands of excellence,” those thoughtful hospitals who have created a
new standard of care by the manner in which they have organized work and by the
existence of a culture of continuous process improvement. All of those
hospitals, too, have boards that are assiduously engaged in appropriate
governance of quality and safety.

I call upon the plaintiff bar to expand their reach in
medical malpractice cases. Name the individual trustees as defendants. Depose them as to the
extent of their activity and oversight with regard to quality and safety
improvement. Ask them if they have
established a corporate goal of eliminating preventable harm. Find out how they measure and monitor harm in
their hospitals. Ask them how much time
in each board meeting is devoted to the topic compared to, say, financial
matters.

Counselors, I think you will find—all too often—a prima
facie case of governance negligence, a factor which is highly likely to support
the underlying contention in your particular litigation.

And think more broadly than individual patient
lawsuits. Curious about targets of
opportunity? The CMS Hospital Compare website might provide guidance. Simply look for those hospitals that have an
incidence rate for, say, central line infections or surgical site infections or
urinary tract infections that is above the national average. Given the standard of care for such items, if
a place has been persistently below average, it’s likely that something is
awry. You might even find that you have
the basis for a class action lawsuit in those hospitals, as their poor performance is
a composite of hundreds of patients.

I have no interest in seeing trustees being held financially
liable at a personal level for their lapses, and, after all, insurance will
protect them from that. But I do have an interest in having them squirm under
the questioning of an experienced malpractice attorney about their failure to
carry out their most important fiduciary responsibility, the well-being of patients
in their institutions.

Saturday, July 11, 2015

The Telluride Patient Safety Summer Camp has continued this week, with a new group of students and new residents joining together with the faculty in Maryland. After a full couple of days in the classroom--often characterized by good-hearted banter as well as hard work--the group boarded a bus for a visit to Arlington National Cemetery. Here, Rosemary Gibson, author of The Wall of Silence and other important works about the health care system, pointed out that the cemetery holds over 300,000 members of the military and their families. She noted, "The military is very good about keeping track of its members, noting everyone who is wounded or killed." The contrast with health care is vivid. In the US, 400,000 people die from preventable harm in the country's hospitals, which would require the construction of a new national cemetery every year. Also, unlike in the military, the victims of medical harm are essentially anonymous. We don't always keep track of the individual cases, and often we don't learn from them.

Rosemary asked the attendees to think about people they had known who had suffered from medical errors and to pay them tribute. Some spoke out, but all seriously considered her words. Here are some of the faces of our faculty and participants.

Thursday, July 09, 2015

Norbert Goldfield is one of the more sophisticated and deep thinkers on the topic of integrating financial incentives with patient care improvement. He and Richard Fuller recently addressed the issue of the segmentation of different kinds of patients under such programs. Here's a teaser:

"It is evident that mental health issues drive increased utilization and,
particularly within Medicaid programs, increase the likelihood of
readmission. Poorly constructed penalties, apparent in many earlier
health management efforts, look at the frequency of readmission at an
institution, typically a hospital, and conclude that the hospital
patient population as a whole has high rates
and therefore the hospital performance merits a penalty. The result is a
push to exclude and dilute the impact of patient populations that
generate this loss, while the providers that treat them are seen as
“loss centers.” The resulting mindset is a pervasive fear in which
complex, high-needs patients that require more resources will uniformly
experience higher rates of adverse outcomes, leading to them being
identified as a problem.

"Exclusion from incentive programs may remove patient populations from
the radar of cost-cutting administrators but will also ensure that
attempts to improve their care will not be a top priority.

"But, with better crafted policies this need not
be the case – in fact the reverse is true."

Wednesday, July 08, 2015

Back in 2011 and 2012, the CEO of Steward Health Care System was prominently covered in the media for his prowess in orchestrating an alliance of the Boston Archdiocese, Democratic
elected officials, the Service Employees International Union (SEIU), and
community organizers to support the sale of the Caritas Christi hospital system to a private equity firm, and meanwhile, too, for hosting a campaign fund-raising event for President Obama. Commonwealth Magazinenoted that Boston magazine, in its April “power issue,” put the CEO on its cover, ranking him 12th among the 50 most powerful people in
Boston, right behind his counterpart at the much larger
Partners HealthCare.

In recent months, the CEO has disappeared. When Quincy Medical Center was shuttered, for example, it was another corporate official who took center stage.

But now, we face a new set of issues calling for executive leadership, as set forth in the New York Times:

The CVS Health Corporation said on Tuesday that it would resign from the U.S. Chamber of Commerce
after revelations that the chamber and its foreign affiliates were
undertaking a global lobbying campaign against antismoking laws.

CVS, which last year stopped selling tobacco products in its stores, said the lobbying activity ran counter to its mission to improve public health.

Last week, Harvard health policy expert John McDonoughsaid that the Chamberdeserves "shame and disgrace" until the group stops its work on behalf "global merchants of death."

Where's the CEO?

The chief executive of the Steward Health Care System, Dr. Ralph de la
Torre, serves on the board of the chamber. In a statement last week,
Brooke Thurston, a spokeswoman for Steward, said: “If the chamber is in
fact advocating for increased smoking, we do not agree with them on this
public health issue.”

That's it?

Steward's owner Cerberus faced some tough public policy and financial issues in the past with its ownership of a major gun manufacturer. Ater the killing of Connecticut schoolchildren, it promised to divest those assets.

Tobacco sales are not synonomous with guns, but tobacco is widely recognized as a major public health hazard. It should be pretty easy for the CEO to say that Steward wants no role in encouraging the use of tobacco products or in supporting an organization that opposes reasonable controls on tobacco sales.

Tuesday, July 07, 2015

This story in the Boston Herald just didn't seem right to me. The lede:

Boston and two other Massachusetts cities are among five places
nationwide with the fastest-rising medical costs [between 2011 and 2013], according to a recent
study — which health care watchers attribute in part to skyrocketing
drug prices and high rates of medical specialization.

Even if health care costs did riser faster here, how could that be attributable to drug prices and high rates of medical specialization? Drug prices in Massachusetts are the same here as elsewhere, and--unless there's something really weird going on--dosages in this state should not have increased at a greater rate than the rest of the country. Likewise for specialization: This has always been a geographical area with lots of specialists. Could this pattern have changed--in the upward direction--in the study period? Doubtful.

But then it got worse:

The study, conducted by consumer health site BetterDoctor, found that
Springfield, Worcester and Boston saw some of the most drastic medical
cost increases between 2011 and 2013, based on Medicare data.

Medicare data? Medicare rates are set by CMS for the entire country, with some local differences due to average wage rates, support of residency programs, and the like. There was no way Massachusetts would have seen a dramatically greater percentage increase in Medicare rates during this period.

Prices for treating severe mental disorders at Massachusetts General
Hospital increased by 78 percent, the study found. Inpatient diagnoses
cost an average of about $61,000 in 2013 — up from about $34,000 in
2011.

Oh my gosh. How'd MGH slip through almost a 100% rate increase?

Well, of course they didn't. Very smart of them to not reply: "MGH declined to comment on the study." It would have been impossible to debunk the entire concept of the story in a sound bite.

I finally found the study on which the news report was written. As best I can tell, the organization used chargemaster figures published by the federal government on which to base the stories. We all know those are essentially irrelevant. But the BetterDoctor people have their own theory of how hospital prices are set. Here it is in a nutshell:

Though the data is from Medicare, the numbers we used to calculate
the fastest rising costs comes from the hospital’s procedure prices. The
price charged to Medicare is the same price that the hospital would
bill an individual’s private health insurance company or an uninsured
person. The true amount Medicare actually pays for each procedure and associated bills is a negotiated portion of the overall cost.

There is an impressive amount of fiction in these three sentences. I won't bother to try to clarify.

But here's what's more striking than all of this. The reporter actually got local experts to give reasons for the non-existent local relative price rises!

One said, “This information is consistent with state reports over the last several years.”

Another said, "When you have a lot of hospitals and doctors in the market, prices go up.” And, "We’ve seen significant increases in what pharmaceutical companies are
charging for not only new-to-market specialty drugs, but pharmaceuticals
that have been on the market for years,”

Seeing what you want to see in randomised controlled trials: versions and perversions of UKPDS data

Randomised controlled trials are objective, free of bias, and produce
robust conclusions about the benefits and risks of treatment, and
clinicians should be trained to rely on them; so says the gospel of
evidence based practice. In this article we argue, using the United
Kingdom prospective diabetes study (UKPDS) as an example, that there is
one stage in the conduct of a randomised controlled trial—the
interpretation and dissemination of results—that is open to several
biases that can seriously distort the conclusions. By bias, we mean the
epidemiological definition: anything that systematically distorts the
comparisons between groups. We will argue that certain biases arise when
different stakeholders assign their individual values to the
interpretation of the final results of randomised controlled trials.

The conclusion about the countermeasure is perfect:When you seek to disprove your idea, you sometimes end up proving it —
and other times you can save yourself from making a big mistake. But you
need to start by being willing to hear no. And even if you think that
you are right, you need to make sure you’re asking questions that might
actually produce an answer of no. If you still need to work on this
trait, don’t worry: You’re only human.

Monday, July 06, 2015

This story demonstrates some pretty ugly things about the Boston healthcare market. Admittedly the story originates from the successful law firm, but the facts seem pretty clear:

BOSTON, June 30, 2015 /PRNewswire/ -- On June 29, 2015, the Suffolk Superior Court issued a ruling in favor of Whittier IPA, Inc. ("Whittier"), an association of doctors based in Newburyport, in litigation against Steward Health Care Network, Inc. ("Steward"). In September 2014, Whittier, represented by the law firm Shapiro Haber & Urmy LLP, filed an action entitled Whittier IPA, Inc. v. Steward Health Care Network, Inc.,
No. 2014-3029 in the Business Litigation Session of the Suffolk
Superior Court. The complaint alleges, among other things, that in
connection with Whittier's decision last year to affiliate with Beth
Israel Deaconess Care Organization instead of Steward, Steward breached
its contract with Whittier by depriving Whittier of millions of dollars
in incentive payments earned pursuant to Payor contracts.

The
Court's ruling yesterday denied Steward's motion to dismiss the
complaint and allowed Whittier's cross-motion for partial summary
judgment. The Court declared that "if incentive payments have been
received by SHCN from Payors in respect of reporting periods during
which Whittier was a member of SHCN, SHCN breached its contract with
Whittier by failing to pay Whittier its pro rata share of those
payments."

Whittier's President, Dr. Salman Ghiasuddin,
said, "We are extremely pleased with the Court's ruling. The Court has
decided in no uncertain terms that Whittier is entitled to the relief it
is seeking in the lawsuit."

To translate. Whittier was previously affiliated with Steward and, while it was, produced clinical results that merited incentive payments from insurers. When Whittier decided to join another network, Steward decided to withhold those funds.

Classy behavior, no?

What a waste of time, effort, and money both to have to pursue and defend against the claims raised in this case. Those are resources that would otherwise could have been used for patient care.